Download Oregon Large Group Dental Limits – 2016 Dental

Oregon Large Group Dental Limits – 2016
Dental Advantage Plans
Dental Advantage
With the Advantage Network, participating dentists agree to write off any charges over and above the
negotiated, contracted fees for most services. When you use a participating dentist, you will not be
responsible for any excess charges and will pay only your plan’s deductible and/or co-insurance amount.
If you choose not to use a participating Advantage Network dentist, or don’t have access to them,
reimbursement will continue to be on the contracted allowable fee. If that non-participating dentist’s fees
exceed the contracted allowable fee, the excess charges are also your responsibility.
Covered Dental Services and
Limitations
Class I Services
Examinations (routine or other diagnostic exams,
including problem-focused exams)
Full mouth x-rays, cone beam x-rays, or
panorex
Two per person per calendar year.
Dental cleaning (prophylaxis and periodontal
maintenance)
Topical fluoride
Three per person per calendar year.
Fluoride varnish
Twelve applications per calendar year for ages 12
and under
Sealants
One application per 60 month period through age
18
Space maintainers
Covered for ages 13 and younger
Athletic mouth guard
One per lifetime for 17 and younger if enrolled in
secondary school
Brush biopsies
One complete mouth series in any 36 month
period. Bitewing films limited to 4 per 6 months.
Two applications per calendar year.
Covered when used to aid in diagnosis of oral
cancer
Class II Services
Composite, resin, or similar restoration
One per surface per calendar year. Posterior
composites paid at corresponding amalgam
restoration. Three or more surface fillings are
limited to one per surface per calendar year.
Simple extractions (or other minor oral surgery)
Covered. Separate charges for alveolectomy not
covered.
Periodontal scaling and root planing and or
cutterage
One procedure per quadrant per 24 month period.
Full mouth debridement
Once every 36 months. Only covered if the teeth
have not received prophylaxis in the prior 36
months. Not covered if performed on the same
date as the prophylaxis.
Class III Services
Complicated oral surgery
Limited to procedures that have been
preauthorized by PacificSource. Separate
charges for alveolectomy not covered.
Pulp capping
Covered only when there is an exposure to the
pulp. Indirect pulp caps are not covered.
Pulpotomy
Covered for deciduous teeth only.
This is a brief summary. Refer to the benefit policy for more details on benefits, limits, and exclusions.
Dental Advantage Limits – OR 2016_Rev 110515
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Root canal therapy
Once every 36 months
Periodontal surgery
Limited to procedures that have been
preauthorized by PacificSource and accompanied
by a periodontal diagnosis and history of
conservative (non-surgical) treatment.
Tooth desensitization
Covered as a separate treatment from other
dental treatment.
Anesthesia
General anesthesia administered by a dentist in a
dental office in conjunction with approved oral
surgery procedures is covered.
Crowns
Limited to the restoration of any one tooth per 60
month period.
Replacement of existing prosthetic device
Only when the device being replaced is
unserviceable, cannot be made serviceable, and
has been in place for at least 60 months
Cast partial denture, full denture, immediate
denture, or overdenture
Limited to cost of a standard full or cast partial
denture.
Denture adjustments and relines
Covered once per 12 months. Separate charges
for adjustments and relines performed within six
months of initial placement are not covered.
Dental implant
Once per tooth space per lifetime
Missing tooth clause
Initial placement of full or partial dentures, fixed
bridges, and implants are provided only if
replacing a natural tooth extracted or lost while
the member’s coverage is in effect. This limit does
not apply after the member has been covered
under the dental plan for 36 months.
Excluded Services
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Aesthetic dental procedures – Services and supplies provided in connection with dental
procedures that are primarily aesthetic, including bleaching of teeth and labial veneers.
Antimicrobial agents – Localized delivery of antimicrobial agents into diseased crevicular tissue
via a controlled release vehicle.
Athletic activities – Any injuries sustained while competing or practicing for a professional or
semiprofessional athletic contest.
Athletic mouth guards for enrolled individuals age 18 and older.
Benefits not stated – Any services and supplies not specifically described as covered benefits
under the group dental plan and/or any endorsement attached hereto.
Biopsies or histopathologic exams – (except when related to tooth structure and preauthorized.
Bone replacement grafts to prepare sockets for implants after tooth extraction.
Charges for broken appointments
Collection of cultures and specimens.
Comprehensive periodontal exams.
Connector bar or stress breaker.
Core build-ups are not covered unless used to restore a tooth that has been treated
endodontically (root canal).
This is a brief summary. Refer to the benefit policy for more details on benefits, limits, and exclusions.
Dental Advantage Limits – OR 2016_Rev 110515
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Cosmetic/reconstructive services and supplies – Procedures, appliances, restorations, or other
services that are primarily for cosmetic purposes. This includes services or supplies rendered
primarily to correct congenital or developmental malformations, including but not limited to, peg
laterals, cleft palate, maxillary and mandibular (upper and lower jaw) malformations, enamel
hypoplasia, veneers, and fluorosis (discoloration of teeth). However, the replacement of
congenitally missing teeth is covered.
Denture replacement made necessary by loss, theft, or breakage.
Diagnostic casts – Diagnostic casts (study models) and occlusal appliances.
Diagnostic casts – Gnathological recordings, occlusal equilibration procedures, or similar
procedures.
Drugs and medications that are prescribed drugs and take-home medicine or supplies distributed
by a provider for any member. As well as premedication drugs, analgesics (e.g., nitrous oxide or
non-intravenous sedation), and any other euphoric drugs, or any take-home medicine or supplies
distributed by a provider for enrolled individuals age 19 and older.
Educational programs – Instructions and/or training in plaque control and oral hygiene.
Experimental or investigational procedures – Services, supplies, protocols, procedures, devices,
drugs or medicines, or the use thereof that are experimental or investigational for the diagnosis
and treatment of the patient. An experimental or investigational service is not made eligible for
benefits by the fact that other treatment is considered by the member’s dental care provider to be
ineffective or not as effective as the service or that the service is prescribed as the most likely to
prolong life.
Fractures of the maxilla and mandible – Surgery, services and supplies provided in connection
with the treatment of simple or compound fractures of the maxilla or mandible.
General anesthesia except when administered by a dentist in connection with oral surgery in
his/her office.
Gingivectomy, gingivoplasty or crown lengthening in conjunction with crown preparation or fixed
bridge services done on the same date of service.
Hospital charges or additional fees charged by the dentist for hospital treatment.
Hypnosis
Indirect pulp caps are to be included in the restoration process, and are not a separate covered
benefit.
Infection control – A separate charge for infection control or sterilization.
Intra and extra coronal splinting – Devices and procedures for intra and extra coronal splinting to
stabilize mobile teeth.
Orthodontic services – Repair or replacement of orthodontic appliances furnished under this plan.
Orthodontic services – Treatment of misalignment of teeth and/or jaws, or any ancillary services
expressly performed because of orthodontic treatment.
Orthognathic surgery – Surgery to manipulate facial bones, including the jaw, in patients with
facial bone abnormalities performed to restore the proper anatomic and functional relationship to
the facial bones.
Periodontal probing, charting, and re-evaluations.
Photographic images.
Pin retention in addition to restoration.
Precision attachments.
Removal of clinically serviceable amalgam restorations to be replaced by other materials free of
mercury, except with proof of allergy to mercury.
Services covered by the member’s medical plan.
Services for rebuilding or maintaining chewing surfaces due to teeth out of alignment or
occlusion, or for stabilizing the teeth.
Services or supplies with no charge, or for which your employer has paid, or for which you are not
legally required to pay, or which a provider or facility is not licensed to provide even though the
service or supply my otherwise be eligible. This exclusion includes any services provided to you
by any licensed professional that is directly related to you by blood or marriage.
This is a brief summary. Refer to the benefit policy for more details on benefits, limits, and exclusions.
Dental Advantage Limits – OR 2016_Rev 110515
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Services otherwise available – These include but are not limited to: Services or supplies for which
payment could be obtained in whole or in part if the member applied for payment under any city,
county, state, or federal law (except Medicaid); Services or supplies the member could have
received in a hospital or program operated by a federal government agency or authority. Covered
expenses for services or supplies furnished to a member by the Veterans’ Administration of the
United States that are not service-related are eligible for payment according to the terms of this
plan; and Services or supplies for which payment would be made by Medicare.
Services or supplies provided outside of the United States, except in cases of emergency.
Sinus lift grafts to prepare sinus site for implants.
Stress-breaking or habit-breaking appliances.
Temporomandibular joint – Services or supplies for treatment of any disturbance of the
temporomandibular joint.
Third party liability, motor vehicle liability, motor vehicle insurance coverage, workers’
compensation – Any services or supplies for illness or injury for which a third party is responsible
or which are payable by such third party or which are payable pursuant to applicable workers’
compensation laws, motor vehicle liability, uninsured motorist, underinsured motorist, and
personal injury protection insurance and any other liability and voluntary medical payment
insurance to the extent of any recover received from or on behalf of such sources.
Tooth transplantation – Services and supplies provided in connection with tooth transplantation,
including re-implantation from one site to another and splinting and/or stabilization. This exclusion
does not relate to the re-implantation of a tooth into its original socket after it has been avulsed.
Treatment after insurance ends – Services or supplies a member receives after the member’s
coverage under this plan ends. The only exception is for Class III Services ordered and fitted
before enrollment ends and are placed within 31 days after enrollment ends.
Treatment not dentally necessary according to acceptable dental practice or treatment not likely
to have a reasonably favorable prognosis.
Treatment of any illness, injury, or disease arising out of an illegal act or occupation or
participation in a felony, or treatment received while in the custody of any law enforcement
authority.
Treatment prior to enrollment – Dental services began before you or your family member became
eligible for those services under this plan.
Unwilling to release information – Charges for services or supplies for which you are unwilling to
release dental or eligibility information necessary to determine the benefits payable under this
plan.
War-related conditions – The treatment of any condition caused by or arising out of an act of war,
armed invasion, or aggression, or while in the service of the armed forces that occurred while on
any PacificSource policy sponsored by the member’s employer.
This is a brief summary. Refer to the benefit policy for more details on benefits, limits, and exclusions.
Dental Advantage Limits – OR 2016_Rev 110515
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